Liver transplant chances tied to distance from center

NEW YORK (Reuters Health) - People who live the farthest
from liver transplant centers may be less likely to get on a
waiting list, and ultimately to get a liver, than those who live
closer, according to a new U.S. study.

The findings illustrate some of the potential unintended
consequences of centralizing medical resources for specialized
care, according to the study's authors.

"When designing these systems, it's important to keep this
geography issue (as) an important feature," Dr. David Goldberg
told Reuters Health. "Otherwise, it could get lost."

Goldberg is the study's lead author from the Hospital of the
University of Pennsylvania in Philadelphia.

He and his colleagues note in the Journal of the American
Medical Association that centralizing healthcare is a way to
control costs, concentrate expertise and limit differences in
the quality of care between regions.

While those approaches may be efficient, any benefit could
be offset by patients having to travel long distances to access
the care, they point out.

To see whether distance to centralized care is connected to
outcomes for patients, the researchers analyzed data on liver
patients within the Department of Veterans Affairs (VA).

The VA has five liver transplant centers nationwide, but
veterans with additional insurance, such as Medicare, can use
other transplant centers.

The researchers analyzed VA liver transplant records from
2003 to 2010. Overall, they had data on 50,637 veterans who were
potentially eligible for transplants. Some 6 percent were put on
waiting lists for a new liver - about half of those at VA
transplant centers.

Of the patients receiving care at VA hospitals within 100
miles of a VA transplant center, about 7 percent were waitlisted
at the VA centers and about 10 percent were waitlisted at any
center.

That compared to about 3 percent having been waitlisted at
VA centers and about 5 percent waitlisted at any center when
veterans were being treated more than 100 miles from the closest
VA transplant center.

Once on a waiting list, those veterans who were living
farther away from a transplant center were less likely to get
transplants, too.

And the likelihood of a liver patient dying over a five-year
period rose with distance.

For example, a veteran living within 25 miles of a VA
transplant center had about a 63 percent chance of being alive
five years later, compared to about a 60 percent chance among
people living more than 100 miles from a VA transplant center.

Organ transplant programs are highly specialized and
organically require centralization, the authors acknowledge.
Doctors would want patients available after a liver transplant
for close monitoring and visits up to several times a week,
Goldberg said.

It's possible that people living farther away from the VA
transplant centers are less likely to even be evaluated for
transplants because of the long distance, the researchers
suggest. Alternatively, it could be that the transplant cannot
move forward because patients and their families can't or won't
relocate closer to the centers.

"While this issue of centralizing care may have many
potential positives by concentrating expertise in one area,
there are these unintended consequences that need to be
considered," Goldberg said.

The study is not intended to be an indictment of the VA's
transplant system, he added. In fact, the VA has approved the
creation of two new transplant centers.

"I think that is one thing the VA should be credited for,"
Goldberg said.